GW1--07167_Well Construction - GW1_20231101

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1.W I Meade InformAtlon;_ •
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WellCaaRaetarTfaom �liWATEA20IVtL = •we = z-7,-- .
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fROM 121C11'
UFSCHIPRONT n ..& --rT� ,,,.. —s_•
ft
NC ell Coma Cetti6emIon Nmnher °-R a dd R _ C (� ^'!
i� UkTERCoSitrinftlri a tFave all :t ti
G' Fain fa''• atel ..
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2.Well Censtructloa?emit It r/ :d �OAZJ 1M1 .-rhlraia�ciasad l8a�il�.- .srsi:aL noH TO OtAMI�/.fifOl/O })jpp�llll'tl�MnT4uCdObpHA7llf ttG tllt.;C TA[(�Q SriT¢onr
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taatry,Sale,Yerlanm,no)- h. tr. �, la.
3.Well Use(check well use): n. o. ' te.
WuerSapptylVep: I
-
70 rtarerca SLO2SIZ� _-,.r- ate'i`
d A ultuml 8M do FRoutwatRtEnre Tinaltress n„►rsiner.
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1N Geothermal(I eaiingWCooifng Supply) • tial Water 0 R• R to,
MI haluatsioYCommercial �Pply(eh ) tr ft to
C�Residetuiai Water S upply(ahatee0
h I '_•lion = :tiAG .==='t. ' s�,ro ;=
Non•WaterSimplyWellMAI TO manta. z�retat�a,tsttratmroa&.u+rourrr
Jul M°aimring C}Reeovesy it. 3 5 b.N i%NE r i,rtid tm.
Injection Well:
• RIAquifer Recharge [DGmundwaterRe,nediatIon ft.
ill Aquifer Storage andRecovery [}SabmLy$earier 'S RASIBGPA • TEOI Mte),n� -:. ,--_• •
Al Aquifer Test AmTEsut. EMPuciedatrramnion •
�StotmwalerDrainage n ft
.ti4ExperimeamlTechnology COSubsidenceControl � n
DI Geothermal(Closed Loop). nTracer
+=I =10:I);IiaHi artarifai'saartion.i2tieeilltniais�0:�-;_��:�sesw=-`v
Geothermal(ReatinenelingReturn) Miter(Klein under921 Remarks) d TO OMQ rSdmr tu,aaeo,,.r rtxk,p.1),Ram,nr,ac)
4.Date Well(s)Completed: Wen inn R R �` l/G f
Sa.Well Locations
t -,e�5iAos a 7�o sad °sue ‘�' r��� c
PaeiitylOwnermamc Facile ima(tt�k°pucaat,) m ft. ir:<r+ ;..-.R
p iaerndd�s'Citj enSZip m R. NOV J Li Zt/23.
( i1 STiz, 3i79-c/-w2,i .r:,in .av
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Cam peteelldentineamnNO.(PIN) G: !?;�i� _... - .
56.Latitude and longitude In deg etaiminutu►setords or decimal degrees: l I
"�f,Prrell6eid, m/sn&cina) J • D 6 g a-
✓v `/ l� f / SS�/Off/ 22 CertiGeatiao: -
N W -eror ,
6.Is(arc)the well(s) Permanent or crop racy � "r"� All.gtri ��r��QT o Si�tmeoCQ�ratiHed Well Contractor
Dote
7.Is this a repair to an elating Well: Yes or By tiring Ellis fibs,,I hereby eaQry the,the sell(:)tar ter m)comma]et actardence
a lea ISA MAC 02C.0100orM SVC 02C:0200 Well Coenrmxlon&ms Worth endthata
(fth+strarepairditIwabromtwdleownwiontufmnation out tapkiet&Maraerho cos,°lrhis+eoardharetenprm 4lit to m10ownere
repetratrder12l moth nun the keehytterfarm.
23.Site diagram or additional well details: •
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8.For GeoprobelDPT or Closed•Loop Ceatherntal Wells hnvieg the saa„ You may use the back of tilis page to!amide additional ttell Site delad&ar:Yeti
construction,only l(3W I is needed.Indicate TOTAL,NUMDBRofwens construction details.You may siso.ellech additional_pages ifsseeesmry.-
drilled:
9.Totel,veil depth below land surfaces QC) ,SRDMITTAI,INSTRUf;P19114 •
ff') 24a.Far All Well: Submit this foal within 30 days of completion of well
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Fermvteptewsnrfuradd adaPie ouf ai(q�taa•md2gl id)
ow top of
N.Static seater level belcasing: `l/d nformationProcess
cansnucrinrs to the follotvitrg
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gxarerlaeetttcboveeabtl we+- (�? Division of Water Resources,IhngUnit,
I 1617 Mail Service Center,Raleigh,NC 27699-1617 •
11.Borehole diameter; (In.)
24h.For Iniecilon Wells: to addition to sending the 6um.to the address in 24a
12.Well consituelion method: PO-to..r y( ebovc,also submit one copy of this Ram within 30 days of completion of well
C e1Ba mteey,cable.elm psuh do.) cwuttemn:I to the follow* •
FOR WATER SUPPLY S ONLY Division of Water Resources,Underground Injection CentralPrOgram1
/) 1636 Mad Service Centel;Resi
Iegh,NC2769N636
Ma.Yh ld(gpm) �/ Method e
U of test: f). ��! "Are.For Wafer Snub/ Inlection Wens: In addition to sending the form to
13�Dialnfettloa type: '� (r Gv S vse address(es)above,also Submit one copy'of this tams within 30 daps of
:Wantcompletion of well construction to the county health department of the county
whereconstrueted.
farmGW l Nott1+(�muoaDepe,m,aetntEavuaameamt •
Qoatay-Divtrioeet%Railway= ; Revised2-222016'